Primary thyroid leiomyosarcoma: a case report and review of the literature

Primary thyroid leiomyosarcoma (LMS) is an extremely rare tumor. We report a case of a 47-year-old male with a rapidly growing neck mass and disfagia. Preoperative investigations were diagnostic of anaplastic carcinoma. Total thyroidectomy with partial esophagectomy and dissection of right infrahyoid muscles was performed. Through histolological and immunohistochemical evaluations a primary thyroid high-grade LMS was diagnosed. At 2 months of follow-up a local recurrence was detected and consequently the patient was submitted to chemotherapy with partial response. He is still alive 9 months after surgery. Diagnosis of primary thyroid LMS is difficult due to its similarity to other more common thyroid tumors. To date, there is no standard therapy and prognosis is poor.

Gastric paraganglioma: case report and review of the literature

Very few cases of gastric paragangliomas have been reported in the literature to date. We report a rare case of parietal gastric paraganglioma fortuitously detected during intraoperative exploration. A 82-years-old woman presented to our emergency room for abdominal pain. On physical examination abdomen was painful on palpation and Blumberg's sign was present. The laboratory exams showed a neutrophilia in absence of leukocytosis. Acute appendicitis was suspected and a laparoscopy was performed. At exploration, the vermiform appendix was normal while a lumpy, hard-fibrous and white-pinkish extraluminal lesion of the anterior wall of the gastric body near the greater curvature of about 2 cm in diameter was present. Laparoscopic resection of the gastric lesion was performed. The patient was discharged in good condition in the fourth postoperative day. Pathologic examination revealed a gangliocitic paraganglioma. The patient is alive and well without evidence of relapse 6 months after surgery. Gastric paraganglioma is a very rare tumor and its diagnosis is very difficult. Surgical excision is the treatment of choice which can be performed successfully with laparoscopy.

Does antithrombotic prophylaxis worsen early outcomes of total thyroidectomy? - a retrospective cohort study

Background

Currently, there is no strong evidence on the effectiveness and safety of pharmacological antithrombotic prophylaxis in thyroid surgery. The aim of this study was to establish whether the prophylactic use of low-molecular-weight heparin (LMWH) could negatively affect the early outcomes of patients undergoing total thyroidectomy.

Methods

Data from patients submitted to total thyroidectomy between February 2013 and October 2017 were retrospectively collected and analysed. Only patients with indication to antithrombotic prophylaxis according to current guidelines were included in the study. Eligible cases were divided into two groups, which corresponded to two distinct periods of our surgical practice: Group A, which included 178 consecutive patients who were submitted to antithrombotic prophylaxis with LMWH, and Group B, which included 348 consecutive patients who did not receive prophylaxis. Primary endpoints were the incidence of post-operative cervical haematomas (POCH) and thromboembolic events. Secondary endpoint was the length of postoperative hospital stay. Statistical analysis was performed by using Student’s t test for continuous variables and Chi-square test for categorical variables. A P value of less than 0.05 was considered statistically significant.

Results

The two groups of patients were comparable in terms of age, gender, thyroid disease, duration of surgery, and weight of the thyroid gland. Overall, no thromboembolic events were registered. The comparative analysis of the other outcome measures, showed no significant differences between the two groups (POCH: 2 cases (1.12%) in Group A vs 8 cases (2.30%) in Group B - p 0.349; Postoperative hospital stay: 2.90 ± 0.86 days in Group A vs 2.89 ± 0.99 days in Group B - p 0.908).

Conclusions

Data from this study do not support or contraindicate the use of antithrombotic prophylaxis in thyroid surgery. However, since thyroidectomy is a closed-space procedure, and even modest bleeding may quickly result in airway compression and death by asphyxia, mechanical prophylaxis should be preferred to LMWH whenever possible.

Trial registration

ISRCTN ISRCTN12029395. Registered 05/02/2018 retrospectively registered.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias

Purpose

Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique.

Methods

A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect.

Results

In a mean follow-up of 48 months (range 10–62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported.

Conclusions

The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Pseudoangiomatous stromal hyperplasia (PASH) presenting as axillary lump: case report and review of the literature

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign mesenchymal breast lesion. There are extremely rare reports of PASH arising in accessory breast tissue. To date, in literature, fewer than 10 cases of PASH occurring in axillary region have been described. We report a case presenting as axillary lump in a young woman. A 20-year-old female presented to our surgical unit for a progressively growing and painful palpable mass of the right axilla for about a year. Before surgery an ultrasound was performed. The patient underwent local excision of the lesion under local anaesthesia. Through histological and immunohistochemical examination a pseudoangiomatous stromal hyperplasia (PASH) was diagnosed. At 6 months of followup the patient is free of disease. It is important to include PASH also in the differential diagnosis of axillary lumps. Histological examination of the surgical specimen and surgery represent, respectively, the mainstay for diagnosis and therapy.

Fixation free femoral hernia repair with a 3D dynamic responsive implant. A case series report

BACKGROUND

To date, no gold standard for the surgical treatment of femoral hernia exists. Pure tissue repair as well as mesh/plug implantation, open or laparoscopic, are the most performed methods. Nevertheless, all these techniques need sutures or mesh fixation. This implies the risk of damaging sensitive structures of the femoral area, along with complications related to tissue tear and postoperative discomfort consequent to poor quality mesh incorporation. The present retrospective multicenter case series highlights the results of femoral hernia repair procedures performed with a 3D dynamic responsive implant in a cohort of 32 patients during a mean follow up of 27 months.

MATERIALS AND METHODS

Aiming to simplify the surgical procedure and reduce complications, a 3D dynamic responsive implant was delivered for femoral hernia repair, in a patient cohort. After returning the hernia sack to the abdominal cavity, the implant was simply delivered into the hernia defect where it remained, thanks to its inherent centrifugal expansion, obliterating the hernia opening without need of fixation. Postoperative pain assessment was determined using the VAS score system.

RESULTS

The use of the 3D prosthetic device allowed for easier and faster surgical repair in a fixation free fashion. None of the typical fixation related complications occurred in the examined patients. Postoperative pain assessment with VAS score showed a very low level of pain, allowing the return of patients to normal activities in extremely reduced times. In the late postoperative period, no discomfort or chronic pain was reported.

CONCLUSIONS

Femoral hernia repair with the 3D dynamic revealed a quick and safe placement procedure. The reduced pain intensity, as well as the absence of adverse events consequent to sutures or mesh fixation, seems to be a significant benefit of the motile compliance of the device. Furthermore, this 3D prosthesis has already proven to induce an enhanced probiotic response showing ingrowth in the implant of the typical tissue components of the abdominal wall, instead of the low quality tissue ingrowth typical in conventional meshes and plugs. The highlighted features seem to represent a more physiologic and updated repair concept of femoral protrusions.

Surgical management of gynecomastia: experience of a general surgery center

AIM

Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia.

PATIENTS AND METHODS

Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study.

RESULTS

Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar.

CONCLUSIONS

Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

External hernia of the supravesical fossa: Rare or simply misidentified?

BACKGROUND

External hernias of the supravesical fossa are considered rare, perhaps wrongly. Highlighting clinical and anatomical features could be useful for correct, preoperative diagnosis, thus avoiding the risk of complications such as incarceration. The study aims to demonstrate that the incidence of external protrusions of the supravesical fossa is higher that supposed. Probably, being mistaken for direct hernias, these hernia types are misidentified and not included in current classifications. This issue deserves attention due to the elevated risk of incarceration related to its distinctive structure.

MATERIAL AND METHODS

249 consecutive open anterior inguinal hernia procedures were analyzed. Hernias were categorized according to the Nyhus classification. A subgroup of direct hernias involved true hernias of the supravesical fossa. Multiple ipsilateral, as well as combined hernias having a multi-component structure, were also considered.

RESULTS

13 true hernias of the supravesical fossa and 19 multiple ipsilateral or combined hernias composed of direct and/or indirect hernia, together with one hernia of the supravesical fossa were identified. 4 true hernias of the supravesical fossa presented signs of incarceration. In three other combined protrusions, the herniated component of the supravesical fossa also showed incarceration of the visceral content.

CONCLUSIONS

Hernias of the supravesical fossa would appear to be more frequent than imagined. These protrusions show a diverticular shape and the base is often tightened by the stiffer medial umbilical fold. This explains the apparently higher tendency to incarceration that distinguishes this hernia type. Preoperative signs of inguinal pain and irreducibility are pathognomonic for correct diagnosis. In these cases, surgical treatment in the short term is recommended.

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region

AIM

The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients.

PATIENTS AND METHODS

The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results.

RESULTS

In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves' disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%).

CONCLUSIONS

Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.

Unexpected post-operative diagnosis of primary rectal melanoma. A case report

AIM

Anorectal melanoma (ARM) is a very uncommon and highly lethal malignancy. Due to its rarity and non-specific symptoms, preoperative diagnosis may be often erroneous and subsequent treatment inappropriate. We report a case of primary rectal melanoma and discuss the current diagnostic and therapeutic challenges.

CASE REPORT

An 87-year-old man was admitted to our surgical unit with a history of progressive constipation, tenesmus, rectal bleeding and transanal mucous discharge. Preoperative investigations, including CT scan and colonoscopy with biopsy, were suggestive for locally advanced low rectal sarcoma and therefore the patient underwent abdominoperineal resection (APR). However, histopathological examination and immunohistochemistry resulted in a postoperative diagnosis of primary rectal melanoma. The patient died 6 months later due to local and systemic recurrence.

CONCLUSION

ARM should always be considered when unusual anorectal lesions are discovered. Regardless of the pathological stage and the extent of surgery, prognosis of ARM remains poor. Thus, whenever feasible, wide local excision is now the preferred treatment, since it is associated with lower postoperative morbidity and better quality of life compared to APR. In our case, although the initial diagnosis was incorrect, APR was justified by the local invasiveness and large size of the tumor.

Acquired abdominal intercostal hernia: case report and systematic review of the literature

PURPOSE

The protrusion of abdominal viscera through an intercostal space under an intact diaphragm is a very rare condition. The aim of this study is to elucidate the etiology, clinical features, and therapeutic options on what several authors call "abdominal intercostal hernia" (AIH).

METHODS

A typical case of AIH of the 9th left intercostal space in a 48-year-old man is presented. A literature search was conducted on the Medline and Scopus databases. Only acquired AIHs (AAIHs) were considered, while lung, transdiaphragmatic, and congenital intercostal hernias were excluded.

RESULTS

Eighteen studies met selection criteria and a total of 20 patients were useful for analysis. Etiology was related mainly to traumatism (65 %) or to previous surgery (20 %). The intercostal defects were mostly located under the 9th rib without significant differences as to side. The main symptom was chest swelling (85 %), often associated with discomfort or pain (76 %). Acute complications such as incarceration and strangulation occurred in three patients. CT was the most employed diagnostic tool (80 %). Early diagnosis was made in 25 % of cases. Seventeen patients underwent hernia repair with either open (73 %) or laparoscopic approach (28 %), and various techniques with and without prosthesis were described. Recurrence occurred in 28.6 % of patients, during a mean follow-up of 8.6 months.

CONCLUSIONS

AAIH should be always suspected when chest swelling occurs after a minor or major trauma, and CT must be promptly performed to rule out diaphragmatic or abdominal viscera injury. This condition requires surgery to prevent serious complications, the first-choice technique should be mesh tension-free repair.

De Garengeot hernia with acute appendicitis

AIM

The presence of the appendix within a femoral hernia sac is a rare condition known as De Garengeot hernia. We report a case of De Garengeot hernia with concomitant appendicitis and a brief review of the literature on the pathogenesis, diagnosis and treatment of this uncommon condition.

CASE REPORT

A 33 year-old woman was admitted to our Surgical Unit with acute-onset pain and swelling in the right groin region. Clinical signs and ultrasound imaging suggested the presence of a strangulated femoral hernia and the patient was operated on in emergency setting. An inflamed appendix was discovered within the hernia sac. Appendectomy via McBurney incision and prosthetic repair of the femoral ring were performed. The postoperative course was uneventful and at the 2 week and 1 year follow-up no signs of wound infection and no hernia recurrence were found.

CONCLUSION

Since clinical signs are non-specific and radiological findings may often be misinterpreted, appendicitis within a femoral hernia sac is often an incidental finding during an emergency operation for strangulated femoral hernia. Appendectomy-associated hernia repair may be performed with or without prosthesis depending on the extent of surgical field contamination.

Incidence and risk factors for trocar site hernia following laparoscopic cholecystectomy: a long-term follow-up study

BACKGROUND

The aim of this retrospective study was to assess the incidence of trocar site hernias (TSH) following laparoscopic cholecystectomy (LC) through a long-term follow-up and to elucidate the significance of several technical and patient-related factors.

METHODS

A total of 313 patients submitted to LC between 2000 and 2004 were included in our study. The pneumoperitoneum was always performed by means of Hasson's technique at the umbilical site and the operative trocars were positioned using either the American technique or the French technique. Closure of the fascial defect was performed only at the umbilical site. The effects of several variables, including age, gender, size of gallstones, co-existing umbilical hernia, complexity of operation, diabetes, obesity, malnutrition, smoking, and heavy manual work on the development of TSH were assessed by univariate and multivariate models.

RESULTS

Thirteen cases of TSH (4.1 %) were detected over a mean follow-up period of 89.8 months (range: 60-128). Of these, 11 (84.6 %) developed at the umbilicus and 2 at the 10 mm subxiphoid site (15.4 %). At univariate and multivariate analysis, gallstones ≥ 2 cm (p = 0.030; OR = 9.95, p = 0.01) and obesity (p = 0.002; OR = 22.93, p < 0.01) were found to increase the likelihood of TSH development.

CONCLUSIONS

After long-term follow-up, the incidence of TSH following LC was higher than expected. The insertion of large trocars at the umbilical site plays a key role in the development of TSH. Other conditions such as obesity and large gallstones can be additional risk factors since the umbilical defect must often be widened in these cases.

[Elastofibroma dorsi: case report and review of the literature]

Elastofibroma dorsi (ED) is a rare, benign, often bilateral lesion of the thoracic wall, occurring most commonly in the infra-scapular region beneath the muscular tissue, generally found in elderly women. Whether ED should be considered as a true neoplasm or merely as a reaction of connective tissue to repetitive minor trauma is still debated. ED has characteristic features but a low incidence and is therefore not always easily distinguished from other benign and malignant soft-tissue tumors. Inappropriate treatment may thus be administrated in the absence of a definitive diagnosis. We report a case of a 51-year-old woman who presented with a right infra-scapular swelling associated with pain and a clicking sensation during selective arm movements. Upon clinical and ultrasound examination, the lesion had the appearance of a deep dorsal lipoma, but intraoperative findings were suggestive of a sarcoma originating from the periosteum of ribs. Nonetheless, marginal surgical excision was performed and the tumor was histologically diagnosed as ED. In conclusion, ED should be always considered in the differential diagnosis of tumors deeply located in the infra-scapular area, especially in elderly women. As it is a benign lesion, surgical treatment is recommended only in symptomatic cases or if a large swelling is present.

Endometriosis of the round ligament: description of a clinical case and review of the literature

We report a case of endometriosis of the round ligament in a 29-year-old woman, who complained of a lump with a diameter of about 2.5 cm in the right inguinal region, which increased in bulk and was accompanied by intense pain during the menstrual period. The clinical suspicion of inguinal endometriosis, supported by ultrasonography and Magnetic Resonance (MR), was confirmed by histological examination of the surgical specimen, which included the mass and the extraperitoneal segment of the round ligament. The authors conclude that the appearance of a lump in the inguinal region associated with subjective and objective changes of the lesion in relation to the menstrual cycle must raise the suspicion of endometriosis among the possible diagnoses.

Operative cholangiography during laparoscopic cholecystectomy: considerations about routine or selective policy

Operative cholangiography (OC) during laparoscopic cholecystectomy (LC) is still a matter of debate regarding its routine or selective use. The present report is based upon a series of 30 selective cholangiographies performed in 290 LC during the years 1999-2004. Indications to OC were decided according to clinical data, liver chemistries, ultrasonographic (US) and intraoperative findings. In cases of unequivocal common bile duct (CBD) stones, a preoperative ERCP was performed and OC was not applied to confirm clearing of the biliary tract. OC was successful in 26 cases (86.6%): in 18 cases a normal cholangiogram was obtained and in 3 cases stones were detected into CBD. These patients underwent a postoperative successful ERCP at a variable interval of time. In 4 cases cholangiograms showed a delayed transit and in a single case a lack of contrast into the duodenum. Such occurrence was due to morphine derivatives employed during anesthesia. The Authors evaluate advantages and drawbacks of routine and selective OC according to personal and other Authors experience. Decision on selective or routine policy should be taken according to each surgeon experience and local facilities. Each laparoscopic surgeon must be able to perform and interpret an OC, specially if he has in mind to develop competence in laparoscopic CBD exploration.

Radical treatment of acute pilonidal abscess by marsupialization

Simple drainage is the most common treatment of pilonidal abscess, but later definitive surgery is often necessary. However, radical treatment can also be performed in a single step by several procedures and even better results. The Authors describe the technique of marsupialization and analyse its long-term outcomes in a retrospective study. Between 1992 and 2001, 43 consecutive patients underwent drainage, curettage and marsupialization for acute pilonidal abscess. The procedure was carried out in outpatient setting (day surgery) after local or spinal anaesthesia. Management of the wound was left to the patient and was periodically checked at our out service. The average operating time was 20 minutes. Complete healing required 4-10 weeks in 95.3% of the patients; a persistent chronic fistula was observed in 4.7%. During the follow-up, 6 recurrences (14.6%) were observed in the healed patients. The treatment was then successful in 81.3% of the cases. Our experience shows that it is possible to carry out a radical management of pilonidal abscess in a single step with a high complete healing rate. Marsupialization proved to be a fast procedure and mainly feasible in the outpatient setting.

[Acute abdomen due to rupture of mesenteric cysts. Observations on a clinical case and review of the literature]

Personal experience based on a clinical case of a young woman with acute abdominal pain referable to acute appendicitis is presented. The surgical procedure was performed through a Mc Burney incision and revealed the rupture of mesenteric cysts; removal of the cysts was carried out without intestinal resection. Post-operative course was uneventful and 2 years follow-up showed no recurrence. Mesenteric cysts are an uncommon pathology, mainly in adult ages. After an analysis of the incidence and etiology, the pathological features and types of clinical presentation are discussed. Diagnosis in asymptomatic cases is usually made in search of other diseases. Complications are rare: rupture, infection and intestinal obstruction. In such cases, the clinical presentation is usually attributable to the main causes of acute abdomen, unless ultrasonography or CT scan are performed. When mesenteric cyst is diagnosed, a laparoscopic approach should be performed, even if in emergency traditional surgery is justified. Total excision of the cyst is necessary to avoid recurrence and obtain a correct pathologic evaluation.

[Lymph node biopsy in the study of lymphomas: from the incisional biopsy to videolaparoscopic lymphadenectomy]

The role of the surgeon in the treatment of lymphoproliferative diseases is mainly addressed to histological diagnosis and staging. The aim of this study was to analyze the results of lymph node biopsies in patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma NHL). Between January 1992 and March 2003, 37 patients (17 males and 20 females, mean age 57 years, range 17-90) were submitted to a node biopsy to determine type of lymphoma and clinical staging: there were 8 HD and 29 NHL. In a single case laparoscopy was adopted to remove abdominal nodes; the procedure was uneventful and the patients discharged in the third postoperative day. The Authors stress the importance of the minimally invasive approach in the management of lymphoproliferative diseases.

[Left pyo-pneumothorax: a rare complication of colon carcinoma]

A case of pio-pneumothorax complicating a splenic flexure colonic carcinoma is herein presented. The patient was a 58 years old male and was submitted 3 months earlier to a colo-colic bypass for a locally advanced tumor infiltrating stomach, spleen, tail of the pancreas and left emidiaphragm. Few days before the admittance in our ward, he experienced fever, anorexia, and severe dispnoea. Treatment was a water seal drainage of the chest evacuating nearly 8 Liters of purulent material where Escherichia coli was found. Death occurred 2 weeks after drainage. From the analysis of the literature thoracic empyema is an extremely rare complication of colonic carcinoma: 5 other cases have been reported so far. Pathogenesis in half of the cases was due to septicemia and in the others to infectious local spreading.

[Our experience in the diagnosis and treatment of diffuse peritonitis]

Acute diffuse peritonitis is still an unpredictable occurrence that hinders patient's survival and is a severe challenge for the surgeon regarding diagnosis and management. The Authors report their experience on 94 cases of acute diffuse peritonitis due to different causes observed during a period of 10 years. Surgical treatment was mainly based on severity of clinica data and general conditions of the patients. Overall mortality was 6.3%. Modern diagnostic techniques, proper usage of antibiotics and accurate timing of surgical procedure constitute the main factors for un update management of peritonitis.

[The general surgeon facing acute abdomen caused of gynecologic cause: diagnostic and therapeutic considerations on 2 cases]

The general surgeon has sometimes to face problems arising from an acute abdomen due to gynecologic causes. Such conditions are mainly found in women in reproductive age; the most frequent pathologies are due to complications of ovarian cysts, perlvic inflammatory disease and extrauterine pregnancy. Some short clinical commentaries are herein presented on two cases of gynecologic acute abdomen: the first case reported is related to an intraperitoneal rupture of a large uterine sarcoma and the second an ovarian neoplasm associated with a diffuse peritonitis from perforation of tubo-ovarian abscess.

[Large villous adenoma of the colon in carcinomatous transformation: colonic resection after endoscopic excision]

Large colonic villous adenomas are benign neoplasms capable of malignant transformation with a higher frequency than other adenomas. Such transformation often requires surgical therapy after endoscopic resection. The aim of the present study was to establish the indications for surgery in a series of 13 cases of large colonic villous adenomas initially submitted to endoscopic resection. The patients (8 males and 5 females; mean age; 62 years) were observed over the period 1993-2000. All endoscopic resections were performed using the piecemeal technique. In 7 cases there were 2 endoscopic sessions and in one case 3; a single case of post-endoscopic bleeding was treated conservatively. In 5 cases, endoscopic resection was deemed not to be radical and these patients were submitted to surgical resection. Histology on the surgical specimens revealed 2 cases of carcinoma (T1 and T2, respectively), confirmation of colonic villous adenoma in 2 cases and the presence of inflammatory tissue in 1 case. Among the patients treated with endoscopic resection alone one death occurred at two years due to lung and systemic metastases probably due to the malignant adenoma. After a review of the literature and on the basis of their own experience, the authors stress the importance of a combined pathological and endoscopic approach to establish when surgery is required.